Big Connections – Mentee Application - Big Brothers Big Sisters of Peel York

This Form Will Take You Roughly 30-45 Minutes To Complete

The Mentee Application Form will take between 30-45 minutes to complete. In order to keep the information private and secure this application must be completed all at once and cannot be saved in stages. Please make sure you have enough time before starting the application. If you have any questions or would like help completing this form, please contact Laura.Elkind@bigbrothersbigsisters.ca Thank you!

MENTEE ACKNOWLEDGMENT

Before completing the application please review and complete the following checklist:*

Each box must be checked in order for your application to be considered complete.

I understand I must be willing to commit to this mentoring relationship and engage with my Mentor in order for my match to be successful

I understand that I will need access to an electronic device that allows me to communicate with my Mentor and the BBBSPY Caseworker assigned to my match

I agree to maintain communication with my Caseworker by e-mails telephone and/or in-person meetings. My inability to maintain this contact may result in the termination of my application and/or closure of the file

I understand that the length of time it will take Big Brothers Big Sisters to match me with a Mentor will vary depending on Mentor availability

I understand that I am not to use or be under the influence of illicit substances such as alcohol and drugs when meeting with my Mentor

MENTEE APPLICATION

We thank you for taking the time to complete this form. We recognize that some of the questions may be sensitive in nature and want to assure you, your responses will be treated respectfully and remain strictly confidential.

Name*

First Last

Gender Identity*

Preferred Name (if applicable)

Pronouns

Please enter your preferred pronouns (i.e. He/She/They). Your response is voluntary.

Phone*

Please provide the best number to reach you at.

Date of Birth*

Email

If applicable.

Address*

If no fixed address, please provide the address of your temporary housing and the name of the organization. For example, 360kids or Blue Door.

Street Address Address Line 2 City Province Postal Code

Ethnic Identity

Your response is voluntary and will be used for statistical purposes only.

Language(s) Fluently Spoken*

How long have you resided in York Region?*

What is your primary means of transportation?*

Do you have access to a phone or electronic device that will allow you to communicate with a Mentor?*

Yes, permanently

Yes, temporarily

Not yet

Please list your interests.*

Please describe the ideal Mentor for you. Consider age, gender, interests, personality traits, ethnicity, etc.*

Please describe what you are hoping to gain from this experience.*

Have you been involved with Big Brothers Big Sisters before?*

Yes

No

If yes, please provide details.

Have you been diagnosed/treated for any major health problems including mental health concerns, physical needs and/or cognitive impairment?*

(I.e. anxiety, depression, addiction, BPD, bipolar disorder, intellectual delay, etc.)

Yes

No

If yes, please state diagnosis and list any medications you are currently taking.

To your knowledge, does anything prevent you from fully participating in this program?*

EMERGENCY/ALTERNATE CONTACT

This can be a close friend, family member, or roommate. If not available, please provide the name of the staff member who referred you to this program.

Emergency/Alternate Contact Name*

First Last

Contact's Relation to You*

Contact's Phone*

APPLICATION ATTESTATION

I hereby confirm that I am the individual for whom this application is being made. I further attest that the information provided here is true and complete to the best of my knowledge.*

Yes

No

Signature*

INFORMED CONSENT

I hereby make a formal application to Big Brothers Big Sisters of York to make their service available to me.

It is my understanding that the intention of the Agency is to match me with a responsible and suitable Mentor for the purposes of shared activities, friendship, and support. I understand that all efforts will be made to select a Mentor with whom I am compatible. In consideration for this service and other valuable consideration provided by Big Brothers Big Sisters of York, I release the agency of all responsibilities and liabilities in connection to their services provided in good faith, to myself. I permit the agency to release any relevant information, including my personal information, to Big Brothers Big Sisters of Canada and their insurers, as may be appropriate in connection with any legal proceeding, inquiry or risk thereof. I understand that the collection of personal information about me will be held in strict confidence and is to be used solely for the purposes of administering the program. I further agree that information about me may be shared, at the discretion of Big Brothers Big Sisters of York, with my Mentor so that my needs in a Mentoring relationship may be best met. I understand that I am under no obligation to accept a Mentor, that the Agency is under no obligation to provide me with a Mentor and that this application is the property of Big Brothers Big Sisters of York. I also agree that I will participate in the Pre-Match Training Program administered by Big Brothers Big Sisters of York.

I have read and understand the Informed Consent agreement. By checking and signing below, I hereby request Big Brothers Big Sisters service. I give my consent to assign me a Mentor. I am aware of and understand the risks, dangers and hazards associated with the above service and agree such service is suitable for myself.

Signature*